Comparison of 30-day postoperative complications after hysterectomy alone versus concomitant vaginectomy for gender affirming surgery

Concomitant vaginectomy is increasingly performed as part of gender affirming surgical care for transgender patients. Hysterectomies performed for gender dysphoria (GD) have low complication rates, similar to hysterectomy for cisgender patients. The objective of this study was to compare 30-day postoperative complication rates between hysterectomy performed for GD and hysterectomy with concomitant vaginectomy for GD. This is a retrospective cohort analysis of the National Surgical Quality Improvement Program (NSQIP) database for the years 2015 through 2020. Cases were selected using procedural codes for benign hysterectomy and vaginectomy. Available diagnostic codes for GD were used for inclusion. Chi-squared, independent t-tests, and Mann Whitney U tests were performed to compare major and minor complication rates between the two cohorts: (1) hysterectomy and (2) hysterectomy plus vaginectomy. Of 334,181 patients undergoing a hysterectomy between 2015 and 2020 for benign indication, 951 were included for GD. This group was stratified into hysterectomy only (n=937; 98.5%) and hysterectomy with concomitant vaginectomy (n =14; 1.5%). Mean age for the total sample was 28.9 ± 8.4 years and body mass index was 28.8 ± 7.4 kg/m2. Medical comorbidities including smoking, diabetes, bleeding disorders, hypertension, and chronic steroid use were not significantly different between groups. Patients undergoing concomitant vaginectomy had increased operative time (259 vs 119 minutes, p<0.001), and surgery was less likely to be performed by gynecologists (78.6% vs. 98.7%, p<0.001). Major or minor complications did not differ by group (3.7% in hysterectomy only vs. 7.1% in concomitant vaginectomy group, p=0.507). Compared to hysterectomy only, concomitant vaginectomy resulted in a higher rate of sepsis (0% vs 7.1%, p<0.001), but there were no significant differences between cohorts for urinary tract infections (1.4% vs 7.1%, p=0.076), superficial surgical site infections (1.3% vs. 0%, p=0.670), or other major complications including blood transfusion, pneumonia, wound disruption, septic shock, deep vein thrombosis, cardiac arrest, and renal impairment. 30-day readmissions and reoperations were not significant between groups. Postoperative composite complication rates for patients undergoing gender affirming hysterectomy only and hysterectomy plus vaginectomy were generally low, and not significantly different. Although operative time and sepsis were significantly higher in the vaginectomy group, the limited number of cases in this cohort makes it difficult to draw conclusions. Overall, the data suggest that performing hysterectomy with concomitant vaginectomy does not appear to result in increased complication rates for transgender patients.